Development of a Consensus-Driven Checklist for Failed First-Pass Intubation Documentation in Prehospital Care: A Modified Delphi Study

BackgroundFirst-pass success is an important airway outcome, but it does not explain why an attempt failed or what changed afterward.Meaningful quality-improvement review requires documentation of patient factors, preparation, equipment, procedural barriers, corrective actions, and rescue strategy.However, a focused chart-audit rubric for failed first-pass prehospital intubation has not been established. ObjectiveThe study's objective is to develop an expert-consensus-derived rubric that defines the documentation content required to reconstruct and review a failed first-pass prehospital intubation attempt. Materials and methodsWe conducted a three-round electronic modified Delphi study in Ontario, Canada.Eligibility was screened before access and required at least five years of relevant airway experience plus at least two predefined indicators of clinical, educational, chart-review, or quality-improvement expertise.Forty-eight eligible individuals were invited to rate 19 candidate domains for importance and clarity on seven-point scales.Controlled feedback and revised scoring anchors were provided between rounds.Consensus for inclusion required at least 80% rating importance as six or seven; consensus for exclusion required at least 80% rating importance as one or two.Items meeting neither criterion were revised and rerated.The study closed after Round 3 when all remaining domains were clearly understood and further unchanged voting was judged unlikely to resolve stable or feasibility-based disagreement. ResultsForty-four of 48 invitees consented and registered.Round 1 included 32 participants, Round 2 included 24, and Round 3 included 20.Among final-round participants with linked demographic records, 15 of 19 were advanced care paramedics and 15 of 19 had at least 10 years of airway-related experience.Thirteen of 19 domains reached consensus for inclusion, six reached no consensus, and none reached consensus for exclusion.Baseline vital signs before intubation, device selection, and alternative airway strategy reached inclusion consensus in Round 3. Patient positioning and airway securement each received 75% support, one response below the 80% threshold.Mean Round 3 clarity ranged from 6.15 to 6.80. ConclusionsThe Delphi process produced a 13-domain, item-anchored rubric for evaluating whether a failed first-pass intubation record contains enough information to support meaningful retrospective review.The rubric is ready for pilot evaluation in paramedic chart review and quality-improvement programs.Field testing should now establish interrater reliability, feasibility, and score interpretation before higher-stakes use.